A quick and easy communication technique borrowed from outpatient family medicine keeps hospital clinicians focused and patients happy.
This article first appeared in the January/February 2018 issue of HealthLeaders magazine.
Step 5: Emphasize human connection
Patient satisfaction was the key measure the UVA study explored. Despite the narrow scope and small sample size, the research supported Allen and colleagues' hypothesis in the following ways:
1. Patients receiving BATHE daily gave their doctors an average score of 4.77 compared with an average score of 4.0 for patients receiving standard care, which is a statistically significant difference.
2. There was no significant difference in the average score given by BATHE and non-BATHE patients when they were asked to rate how much time they spent with their doctors.
3. Family medicine doctors reported that using BATHE didn't add significantly to the time they spent with patients; it just better focused their conversations.
4. Physicians also noted that patients receiving BATHE were less likely to seek extra attention from doctors or nurses out of anxiety.
"Notably, patients in the intervention group were not more likely to perceive that their physician spent adequate time with them, showed them respect, or communicated well about their care," the researchers wrote. "Rather, they were more likely to report that their physician was friendly and showed a 'genuine interest in me as a person.' The added value of the intervention appears to have been to create a daily moment where the physician acknowledged the patient as a whole person rather than solely as a medical patient."
The fact that it wasn't the extra two to five minutes that boosted patient satisfaction but the feeling of human connection was an unexpected and powerful finding, says Pace.
"And then these results held even though lots of different providers were doing the intervention on different days," she says. "I think it speaks a lot to this being an intervention that anyone can do and make a difference. It was really special to see that come through in the results."
Determining how to pay doctors in various markets and specialties has become more nuanced than ever.
Physician compensation was already complex before the healthcare industry began its protracted shift from volume to value.
A recent survey produced by Integrated Healthcare Strategies, a division of Gallagher Benefit Services, looks at how healthcare organizations are updating their physician pay practices to reflect an evolving reimbursement climate.
Aurora Young, a managing director in the physician services practice of Integrated Healthcare Strategies, gives her take on the survey data and market trends. Here are four takeaways.
1. Medians are becoming less meaningful
While national survey data remains the foremost factor in physician pay practices across specialties, it's far from the only factor at play. More local variables such as payer reimbursement, clinician supply and demand, and the prominence of quality incentives (which may be offered as carve-outs or additional earnings) make arriving at an offer decidedly more complex.
In surgical specialties, for example, productivity-based payment rates are determined by national survey data (85%), regional survey data (42%), local market norms (38%), financial affordability (37%), and negotiated rates (18%), according to the survey, which allowed participants to select multiple production metrics.
"Local factors mean that not all organizations can afford to pay at the median," says Young. "They're being more nuanced than in the past. They're not just opening a book, pointing to the median, and saying, 'That's what we'll pay.' "
2. The move to value isn't as slow as it looks
Consistent with other national survey data, healthcare organizations are tying a rough average of 10% of physician compensation to quality or value-based incentives.
Despite the industry's seemingly drawn-out transition to value-based care, that level is "about right," says Young.
"Most of our clients will say that their actual reimbursement coming from these value-based initiatives is less than 5%. So to be at 10% of pay for physicians is actually outpacing reimbursement a bit. They're recognizing that they need to be preparing themselves and aligning their pay models with what they expect to be an increase in those value-based initiatives and the reimbursement dollars flowing from that."
On the other hand, organizations in regions with reimbursement moving more quickly into value-based care are more aggressively targeting 20%–30% in performance-based pay.
"It's a balancing act for organizations," Young says. "You don't want to necessarily be too far ahead of your market, and you don't want to be behind the game."
Note that Gallagher's 2017 survey reveals that 84% of physician compensation plans included a qualitative and/or operational incentive opportunity, an increase from 80% in 2016.
3. There's more to productivity than meets the eye
"What might be driving compensation per work RVU up, even though production hasn't changed, is the layering of additional payments into the structure," Young says.
"You're asking your physicians to spend more time to support non–wRVU generating/value-based initiatives, such as advanced practice clinician supervision and medical directorships. Those are additional cash compensation components in the published data, so they are helping to drive up those rates per wRVU."
4. Sometimes metrics miss the mark
Across specialties, fewer than half of physicians surveyed (41%–47%) earned most (81%–100%) of the incentive dollars they had the opportunity to acquire. Meanwhile, almost one-third (22%–32%) took home 20% or less of the incentives offered.
Having high numbers of physicians falling close to all-or-none extremes may indicate that the difficulty of achieving incentive targets was not well-matched to the level of risk organizations sought.
"One conjecture is that organizations whose physicians are earning all of the incentive may have attempted to establish metrics at hard-to-earn levels and missed the mark. And some organizations that moved quickly into value-based payments could have unintentionally set their metrics to stretch-level performance," Young says.
Finding the right balance is challenging for organizations, as is determining whether to offer incentives as an add-on or carve-out. "It comes down to financial sustainability," she says. "At most organizations, reimbursement is not going up. If they have the same pool of funds to work with, and no additional dollars from payers, they're going to be more fiscally conservative about how they incorporate these incentives."
Clinician burnout isn't necessarily a one-time event. One doctor who experienced recurrent burnout during his 20-year medical career shares his story.
Experts estimate that the cost to replace a burned-out physician who has left an organization ranges from $250,000 to $1 million—and that doesn’t account for losses due to lost productivity or medical mistakes.
While researchers work to come up with a broad calculation of burnout costs, the emotional toll on clinicians is undeniable, especially since burnout isn’t necessarily a one-time occurrence.
There are circumstances in which a physician at your organization may return to medicine after a burnout.
Chi Huang, MD, SFHM, FACP, is executive medical director of general medicine and hospital medicine shared services and section chief of hospital medicine at Wake Forest Baptist Medical Center in Winston-Salem, North Carolina, and an associate professor of internal medicine at Wake Forest Medical School. He offers his insights about what you should know to foster your team's long-term well-being.
The following transcript has been lightly edited.
HealthLeaders Media: Professional burnout is typically presented as an isolated occurrence. Do you think your experience of burning out and recovering multiple times is unusual?
Chi Huang, MD: I don't know if "re-burnout" is a new phenomenon to healthcare, or it's just me burning out two to three times in my career.
The first time I burned out was when I was an attending in the United States and also helping to start a nonprofit working with street children and child prostitutes in South America. Juggling work as a physician running a nonprofit, and being a father and husband was a great deal of pressure on many fronts. It wasn't until I had this experience that I really understood what burnout was and was able to define it.
I burned out two other times during my career as a physician leader and, by then, I was able to recognize and label it.
HLM: Perhaps we don't hear much about re-burnout among physicians because many of them quit. Why have you kept coming back to medicine?
Huang, MD: I just love taking care of people. That's why I started the nonprofit, which has since ended. But I love taking care of kids on the streets at 2 a.m. when no one else will; I love taking care of patients on the floor at the end of life or the beginning of life. I just love being able to help people.
There are several reasons that I've been able to return to medicine.
One is that I've been blessed to be around people who are able to help understand me and what's going on in the burnout and mental health realm. They understand that this is something that occurs and can be addressed.
I also have really good mentors within and outside of medicine who have advised me not just how to grow as a leader but also as a person.
I've learned to own burnout as an issue I need to face. For me, that means recognizing that it occurs and finding steps to what I call self-care.
Finally, the latest study by Tait Shanafelt, MD, indicated that 54% of the physicians in the United States are burnt out. We, as physician leaders, need to continue to address this epidemic for our own sake and the sake of our patients and families.
HLM: How do you define self-care?
Huang, MD: For me, it means getting eight hours of sleep a night, engaging in rigorous exercise at least three to four times per week, writing short stories, and turning off my office cell phone and putting it in the proverbial glove compartment of my car at the end of my workday.
On my work calendar, I block off Friday mornings as my "professional day," during which I recharge my batteries by reading medical journals, writing papers, and doing other things for myself that help me be whole as a physician leader.
I've also at various times sought professional help from executive coaches and mental health professionals trained in cognitive behavioral therapy and mindfulness.
Huang, MD: I have learned the hard way that being a workaholic and/or ignoring burnout are simply not worth it—in terms of my health, my family, or even as a physician leader.
So as a leader, I've tried to be vulnerable and open about my experiences with burnout, and explain to my team that I never want any of them to go through that suffering.
I also try to model good self-care and create a culture in which people support one another in carrying that out. I'm trying to debunk the notion that being a hard worker does not means going to every meeting and working late all the time. Being effective does not mean sending more emails.
I challenge the misconceptions by saying, "You are adult professionals. I expect you to take care of patients well and complete projects with deliverables on time, and that's the outcome that we're all trying to achieve."
Establishing that intention as a given for all of us, I will leave to go to my daughter's ballet recital. I have no qualms about that.
I try to lead by example; if I'm doing it as the boss, then other people will feel more comfortable taking a lunch break or what have you.
Finally, I try to create an environment where people feel safe to talk about what's going on in their lives in a confidential manner. And if someone is having a personal struggle—for example, losing a loved one or going through depression—our culture is that we support that person so he or she has time to recover and heal.
The American Medical Group Association calls on the government and other stakeholders to remove impediments to value contracts.
Medical groups and health systems expect that nearly 60% of their revenues from Medicare will be from risk-based products by 2019 and that Medicare Advantage will account for an increasing percentage of their business, according to a survey from the American Medical Group Association (AMGA).
AMGA's third annual risk survey examined how and when AMGA members are transitioning from reimbursements based on volume to payment models based on value.
Key findings include the following:
Medicare FFS payments are expected to decrease by 17% by 2019, while commercial fee for service payments will decline by 11%—rates slower than predicted by both the 2015 and 2016 surveys.
Fifty-nine percent of respondents stated that they have little to no access to commercial risk products in their local markets, which represents a small increase in payer engagement since 2015.
Revenues generated by accountable care organizations (14%–15%), whether federal or commercial, are not expected to increase by 2019, perhaps reflecting the plateauing success in ACOs.
In 2017, capitated payments equaled 17% of total payments to providers, while shared risk payments made up 13% of total payments.
Despite medical groups' progress toward risk-sharing, AMGA members are pursuing value in an uncertain environment, AMGA noted in a whitepaper.
"Commercial payers remain largely unengaged in the risk market. Lack of data sharing is a significant burden in succeeding in value arrangements, yet this practice remains endemic in the industry… . To reward this movement, Congress and HHS must address impediments to taking risk quickly or the groups that are most willing to make this transition will pare back their risk-based efforts," the authors concluded.
Patient ratings can help make or break an ambulatory surgery center. An orthopedic surgeon shares his top tips for ensuring satisfied consumers.
Ambulatory surgery centers (ASC) can be an appealing option for patients—and a sound revenue stream for systems and physicians. Patient satisfaction scores can play a key role in an ASC's success, but obtaining high patient ratings can be difficult.
Nicholas Frisch, MD, MBA, is an orthopedic surgeon with Ascension Crittenton Hospital in Rochester, MI, and Bald Mountain Surgery Center in Lake Orion, MI.
The following transcript has been lightly edited.
HealthLeaders Media: What are some key challenges to achieving patient satisfaction in ASCs in particular, as opposed to hospitals or other ambulatory settings?
Nicholas Frisch, MD: In an ambulatory environment, you don't have all of the resources you would have, say, at a large academic medical center. So you have to be prepared for situations that could arise and require additional instrumentation or equipment. The preparation to have that available is a challenge for everybody, and requires a bit more work on the front end for ASCs.
The other issue is managing the patients' expectations in terms of what they want out of the experience. Patients are drawn to ASCs because they want a more personalized experience compared to going to a big hospital.
But not every patient is a candidate for outpatient surgery. While 60%–70% of my patient population, for instance, might be candidates from a medical standpoint, you have to take into account the social realities of their lives and circumstances. For some patients, it's wiser to operate in a hospital in case problems arise. If all is well, they may still be able to go home the night of surgery. I call all of my patients the night after surgery to make sure everything is OK.
Finally, I can't emphasize enough the importance of creating the right infrastructure. We try to make sure there's an opportunity for people to come to our clinic if there's an issue before their follow-up appointment, which may be three weeks after surgery.
We had to increase our staffing to do this, but we also reach out to patients at critical intervals, such as one week out or when they start outpatient physical therapy to make sure everything is in order. And we have to train staff to answer questions and concerns and identify which people need to be seen in the clinic.
Patients are much more comfortable when they know they can get ahold of you and that you can see them if they need to be seen.
HLM: What ways do you measure patient satisfaction?
Frisch, MD: It can be different everywhere, but for my center it's a bit of a hybrid approach. We have some internal surveys to look at satisfaction and track our patients and their experience. We're actively trying to engage them in that process in terms of ways we can improve their subjective perception of their experience.
We also track functional outcome metrics, which reflect objective information about how patients do after surgery.
HLM: How can ASCs optimize patients' health—and the odds of good outcomes—prior to surgery?
Frisch, MD: An app we use called PeerWell makes my job a lot easier. Unfortunately, we don't have hours and hours to sit down with patients and have multiple discussions to go through all of the material they should understand.
For example, people with poor nutrition may be predisposed to issues with wound healing and infection, so we target nutrition aggressively. For most patients, the content in PeerWell's PreHab program helps patients understand how they should eat. But for patients who need extra assistance, we'll send them to a nutritionist before surgery.
HLM: What's your advice for meeting patients' expectations specifically when it comes to pain management while practicing more careful prescribing? After all, a study published in JAMA Internal Medicine just last month showed that patient satisfaction declines when clinicians say 'no' to their requests.
Frisch, MD:Ambulatory surgery, when it comes to joint replacement, has really pushed what we call perioperative pain management, which uses multimodal protocols.
It used to be that you could give out narcotics and manage the pain, and patients never really called complaining of pain. But it wasn't addressing the problem. It was a reactive approach.
Now, we're proactively targeting pain—which means for a surgery center we have to be organized—so that when patients leave, they have everything they need available. We give patients their prescriptions in advance so they can have them filled, and we have them bring them on the day of surgery. There, we'll go over the medications and a schedule of when to take them. And we try to target non-opioid medications, such as Tylenol, NSAIDs, and gabapentenoids.
Whereas we used to give medications to take as needed, now we've put together a schedule for the first two weeks, in which many of these medications are scheduled for every six to eight hours, so that the only time they need a narcotic is for breakthrough pain.
Doctor pay should be based on comparable work, not personal characteristics, urges the American College of Physicians in a new position statement.
“Physicians, like those in other professions, should be assured that their work is being valued equally,” said Jack Ende, MD, MACP, president of the American College of Physicians, regarding a position statementapproved by the Board of Regents on November 19, 2017.
“Salary and compensation should never be negatively impacted by a physician’s personal characteristics, including gender, race, ethnicity, religion, nationality, sexual orientation, and gender identity,” he continued.
Pay-equity principles promoted by the ACP include the following:
Physician compensation (including pay, benefits, clinical and administrative support, clinical schedules, institutional responsibilities, and where appropriate, lab space and support for researchers, etc), should be equitable. In other words, compensation should be based on comparable work at each stage of doctors' professional careers in accordance with their skills, knowledge, competencies, and expertise.
Transparency is needed in physician compensation arrangements to ensure that physicians regardless of characteristics of personal identity (including, but not limited to, race, gender, religion, nationality, sexual orientation, and gender identity) are paid equitably for comparable work.
The healthcare industry should study, develop, promote, and implement policies and salary reporting practices that reduce pay disparities and bring transparency to physician salaries in a manner that protects the personal privacy of individual physicians.
Stakeholders should conduct further research to identify the adverse effects that one’s characteristics of personal identity have on physician pay, with resultant effect on well-being and burnout, and how those affect the strength of the medical workforce.
The ACP shares these remarks citing background evidencedemonstrating that gender, race, sexual orientation and gender identity all impact compensation—and that having multiple, different personal characteristics compounds compensation disparity.
Virtual medicine practice is more than technological competence. A doctor who proposed the idea of telemedicine certification advocates why this is so.
As medicine sees advancements in technology and expansion of knowledge in care delivery, specialties and their commensurate board certifications continue to proliferate.
With telemedicine use and applications growing, a premier candidate for this process may be a specialty representing the "medical virtualist," proposed two physicians at New York-Presbyterian (NYP) in a recent JAMA Viewpoint.
Paper coauthor Michael Nochomovitz, MD, chief clinical integration and network development officer at NYP, offers his insights on this topic.
The following transcript has been lightly edited.
HealthLeaders Media: What motivated you to share this idea?
Michael Nochomovitz, MD: Telemedicine started out with coughs, colds, rashes—easy things. But now with the technology improving and remote monitoring expanding, the need for a more sophisticated approach has become apparent.
A telemedicine visit isn't the same as FaceTiming your cousin. It involves a true medical interaction that needs to be defined and categorized, and there are a number of people around the country who have set standards of their own, but they haven't made any consensus because it's too early.
Having said that, there are going to be people who do this for a living. There will be a career where you don't touch a patient, and there will have to be a set of core competencies that will need to be codified.
HLM: Were you surprised by the level of reaction to your article?
Nochomovitz, MD: I don't know. This is the first time the idea of a new specialty has actually gone public. We coined the phrase "medical virtualist," and now people are chewing on the concept.
I think one of the reasons JAMA published it is that the idea is new and somewhat disruptive, and it's unclear where it goes from here and how it will impact the rest of healthcare.
We're excited by the response because the discussion is so needed.
There isn't a major healthcare organization in the United States that doesn't have telemedicine and telehealth as a priority. Now there almost needs to be a pause—a timeout—and ask what we are going to expect from the doctors who do this.
HLM: What is your response to those who say that a telemedicine certification and specialty are unnecessary?
Nochomovitz, MD: Those who say it's not necessary just haven't done enough of it, and they haven't been exposed enough to the complexity of doing telemedicine with complicated patients.
HLM: What are some of the core competencies needed for medical virtualists?
Nochomovitz, MD: One important idea is that of "webside manner." Doctors that see patients in an office each have a different personality. Some doctors are engaging; some are not. That will be exaggerated in a remote visit.
There are techniques that need to be taught on how people speak, where they look, how they engage, what they look for, how they reassure patients, how they address technical glitches, and how they recognize that a particular issue is not within the scope of the telehealth visit without making the patient nervous.
Keep in mind that with increased use of remote monitoring, doctors are going to have much more information at their disposal, and the physicians have to use some skill to put together the patient's complaint, the patient's appearance, and all of this additional information about the patient's prior or current activity. It's a different way of looking at the doctor-patient interaction.
HLM: If a certification were to become a reality, do you think it would deter physicians from pursuing telemedicine?
Nochomovitz, MD: Provided that the process is not overly onerous, I think that certainly the new generation will embrace it because technology is so engaging. And we're so used to using it in our daily lives that we have a blurring of the edges between lifestyle technology commodities and applications in healthcare.
I don't think there's going to be a problem with adoption. Doctors will want to do it right.
Despite some reassuring findings, authors say more research is needed to identify hospital-level factors associated with the quality and costs of care related to locum tenens physicians.
Patients treated by a locum tenens physician in the hospital are no more likely to die within a month of discharge than those treated by full-time doctors, according to a study conducted by Daniel M. Blumenthal, MD, MBA, of Massachusetts General Hospital in Boston, and colleagues. The findings are published online in JAMA.
While the retrospective analysis of 1.8 million Medicare beneficiaries hospitalized during 2009–2014 found no statistically significant difference in 30-day mortality between the two groups of patients—8.7% for those cared for by staff physicians versus 8.8% among those treated by temporary doctors—the hospitals' pattern of locum tenens use played a notable role in mortality.
In particular, hospitals that used substitute physicians less often had somewhat worse patient mortality outcomes. In the lowest third of locum tenens intensity, adjusted 30-day mortality was 11.63%.
As for other metrics, patients treated by locum tenens physicians had significantly higher Part B spending, significantly longer mean length of stay, and significantly lower 30-day readmissions.
"Our findings so far are reassuring, but some of the trends we found demand that we look more closely at how the system works in a more granular way,” said study senior author Anupam Jena, MD, PhD, the Ruth L. Newhouse Associate Professor of Health Care Policy at Harvard Medical School.
The Patient-Centered Outcomes Research Institute has awarded The Fenway Institute funding to study the best ways to collect data regarding sexual orientation and gender identity.
The Fenway Institute, a Boston-based nonprofit interdisciplinary center dedicated to ensuring cultural competence in healthcare for the lesbian, gay, bisexual, and transgender (LGBT) community through research and evaluation, training and education, and policy and advocacy, has been approved for a $2,075,915 funding award by the Patient-Centered Outcomes Research Institute (PCORI) to determine the best way to train community health center staff in the collection of sexual orientation and gender identity (SOGI) data.
PCORI is an independent, nonprofit organization authorized by Congress in 2010. Its mission is to fund research that will provide patients, their caregivers, and clinicians with the evidence-based information needed to make better-informed healthcare decisions.
To meet that goal, the project will also evaluate the impact of that enhanced data collection on health outcomes for LGBT patients.
According to experts who spoke with HealthLeaders Magazine, the typical "not counting" of these individuals represents just the beginning of missed opportunities in best serving their needs. Furthermore, insensitivity by healthcare providers can lead these patients to avoid care altogether.
However, many healthcare providers lack proper training to ask questions about sexual orientation, sexual behavior, and gender identity, while social stigma prevents many patients from volunteering this information.
In addition, electronic health record (EHR) systems do not currently include standard ways to collect SOGI information. Without this knowledge, providers cannot properly identify and address health disparities affecting their LGBT patients.
"This new PCORI award will allow staff at The Fenway Institute to evaluate health outcomes before and after community health center personnel receive trainings about LGBT health from Fenway’s National LGBT Health Education Center. The study could help transform LGBT clinical care nationally by demonstrating the importance of providers receiving specialized training," said Kenneth H. Mayer, MD, co-chair and medical research director of The Fenway Institute, who will serve as principal investigator on the project.
Advanced practice clinicians are crucial to helping health systems ensure patient access, but numerous factors can undermine team-based care if left unchecked.
Despite health systems' essential need to embrace team-based care, physicians aren't always crazy about working with advanced practice clinicians, and vice versa. Clinicians rarely complain out loud, however, and often enter into collaborative contracts when they'd rather be in charge.
Ignoring that elephant in the room comes at a cost, says Liana Orsolini PhD, RN, ANEF, FAAN, care delivery and advanced practice system consultant at Bon Secours Health System in Marriottsville, MD.
For starters, when tensions get bad enough that a nurse practitioner or physician assistant quits (often with a mere two weeks' notice), it costs roughly $150,000 to recruit and hire a new APC, says Timothy Willox, MD, chief medical officer for Bon Secours Virginia Medical Group.
To help promote better teamwork from the get-go, consider the following steps:
1. Clear a Landing Spot
Part of physicians' reluctance to work with APCs is generational. If a physician has worked on his own for 30 years, notes Orsolini, changing the model may be a tough sell. "And you've got to respect that," she says.
Rather than waiting for problems to arise, identify any animosity or discomfort upfront, says Willox. "You've got to work through that before you even bring in an APC."
This task is twofold. "Breaking down the barriers is part helping physicians understand the value of the APC, but it's also identifying the right provider, the right practice, and the right environment to bring that APC in," Willox says.
To that end, Bon Secours' nascent onboarding committee involves both APCs and physicians to help make sure both sides are comfortable in their roles, they have what they need, and they're comfortable in their environment, he says.
Likewise, healthcare organizations must set and communicate clear expectations for APCs and physicians, including the circumstances under which they'll work independently or collaboratively.
But don't stop there. The rest of the staff, as well as patients, need the same information. For example, the appointment scheduler in a medical group should be well-versed in what types of visits are appropriate for an NP vs. a PA vs a physician.
This step may not be as obvious as it sounds, notes Orsolini.
"There's so much ubiquitous role confusion—and that's not talked about either," she says.
She recalls a situation at one practice in which an NP was seeing just eight patients a day, simply because the scheduler didn't understand what the NP did. "Once the NP finally asked what was going on and explained to the person making the appointments what she did, she got to see more patients," Orsolini says. "We as a health system can't afford for an NP to see eight patients a day."
3. Ease the Transition
Physicians' concerns about APC competency can also lead to pushback, says Willox.
"For example, we just introduced NPs into our hospitalist program. They are some very, very sick patients, and it takes a little while for that NP to have the experience and the ability to be able to manage those patients by themselves," he says. "Physicians have to be comfortable with the skill level of an APC before they let them loose."
One way Bon Secours is working to build competency among new APCs is by piloting a transition-to-practice residency.
"It's the kind of program where a new NP who doesn't really feel comfortable jumping in and taking their own panel may have a yearlong transition where they rotate through specialties and primary care, and gradually as they go through the program they're empowered to take on more and more of their own patient responsibility," Willox says.
"At the end of the program we all feel much more comfortable allowing them to transform into an independent provider in a practice."
Bon Secours has hired almost all graduates of the program, he adds. "And they've all turned out to be superstars."
